CDEO ASSESSMENT GUIDE 2025
|MOST COMMON QUESTIONS WITH CORRECTLY
VERIFIED ANSWERS (the recent quizes)|ALREADY
A+ GRADED|GUARANTEED PASS
What is a documentation challenge for services provided by providers in an inpatient facility?
Documentation may not include the progress note for a subsequent inpatient encounter.
Documentation deficiencies may not be identified until after the provider has left.
Providers may not have access to the entire record for the inpatient stay.
Providers may not have access to the hospital EHR to document the inpatient encounters -
Documentation deficiencies may not be identified until after the provider has left.
Adhering to the CMS documentation guidelines for E/M services will meet the clinical
documentation requirements for all encounters.
Yes; E/M documentation guidelines help the provider document all requirements needed for a
detailed record.
Yes; CDI is a proactive approach to ensure E/M services are reimbursed correctly.
No; the CMS documentation guidelines provide the least expected documentation to support a
visit. - No; CDI programs do not include monitoring of the correct coding of E/M services.
Response Feedback:
The basic CMS documentation guidelines for E/M services include the least expected
documentation to support an encounter. Quality is going above and beyond the basic
information.
Which of the following documentation deficiencies has a negative impact on patient outcomes?
,Answers:
Failure to indicate the date of the patient's last blood test
Failure to include the instructions for post-procedure care and potential complications
Failure to sign the patient's medical records provided by another physician
Failure to report the patient's pharmacy preference for insurance participation - Failure
to include the instructions for post-procedure care and potential complications
Although all the choices are deficiencies in capturing patient information, failure to inform a
patient of potential postoperative complications could impact the patient's recovery. In this
question, you are determining the option that affects clinical care of the patient.
Why is it important to involve physicians in clinical documentation improvement (CDI)
programs?
Answers:
It encourages physician participation.
It helps justify the need for CDI programs.
It will eliminate the need to query providers.
It will help providers' time management. - It encourages physician participation.
Response Feedback:
Getting physicians involved in CDI helps to gain physician buy in and encourages other
physicians to participate and is a great way to educate physicians.
How can an effective CDI program improve patient outcomes?
Answers:
Maximize the reimbursement received
,Prohibit claim processing errors
Provide a detailed record of the care provided to the patient
Allow providers to support higher levels of E/M services - Provide a detailed record of the
care provided to the patient
Response Feedback:
The main goal for detailed medical records is to promote the continuity of care for the patient.
This allows providers to communicate with each other on the care that has been provided to
the patient. Coding higher-level services that are not medically necessary is not a goal to
improve patient outcomes.
In addition to facilitating high quality patient care, a properly documented medical record
verifies and documents precisely what services were actually provided. Other than the site of
service, the medical record may be used to validate:
Answers:
The appropriateness of the services provided
The patient's certificate of birth
The identity of the patient's extended family
The cost of healthcare benefits used for the year - The appropriateness of the services
provided
Response Feedback:
In addition to facilitating high quality patient care, a properly documented medical record
verifies and documents precisely what services were actually provided. The medical record may
be used to validate: (a) the site of the service; (b) the appropriateness of the services provided;
(c) the accuracy of the billing; and (d) the identity of the caregiver.
To maintain an accurate medical record, what is the recommended appropriate time for
provider documentation?
, Answers:
Within 48 hours of patient visit
A minimum of bi-weekly
During the encounter or as soon as possible
The end of each day for all encounters that day
Response Feedback:
The best way to achieve the most accurate, detailed documentation is for the provider to
document the encounter/services as soon as possible after (if not during) the encounter. -
During the encounter or as soon as possible
Which of the following sources, other than federal healthcare plans, may request the medical
records?
I. Patients
II. Providers involved with the patient's care
III. Employers for worker's compensation claims
IV. Private payers
Answers:
II and III
I, II, and IV
I, III, and IV
I, II, III, and IV
Response Feedback:
|MOST COMMON QUESTIONS WITH CORRECTLY
VERIFIED ANSWERS (the recent quizes)|ALREADY
A+ GRADED|GUARANTEED PASS
What is a documentation challenge for services provided by providers in an inpatient facility?
Documentation may not include the progress note for a subsequent inpatient encounter.
Documentation deficiencies may not be identified until after the provider has left.
Providers may not have access to the entire record for the inpatient stay.
Providers may not have access to the hospital EHR to document the inpatient encounters -
Documentation deficiencies may not be identified until after the provider has left.
Adhering to the CMS documentation guidelines for E/M services will meet the clinical
documentation requirements for all encounters.
Yes; E/M documentation guidelines help the provider document all requirements needed for a
detailed record.
Yes; CDI is a proactive approach to ensure E/M services are reimbursed correctly.
No; the CMS documentation guidelines provide the least expected documentation to support a
visit. - No; CDI programs do not include monitoring of the correct coding of E/M services.
Response Feedback:
The basic CMS documentation guidelines for E/M services include the least expected
documentation to support an encounter. Quality is going above and beyond the basic
information.
Which of the following documentation deficiencies has a negative impact on patient outcomes?
,Answers:
Failure to indicate the date of the patient's last blood test
Failure to include the instructions for post-procedure care and potential complications
Failure to sign the patient's medical records provided by another physician
Failure to report the patient's pharmacy preference for insurance participation - Failure
to include the instructions for post-procedure care and potential complications
Although all the choices are deficiencies in capturing patient information, failure to inform a
patient of potential postoperative complications could impact the patient's recovery. In this
question, you are determining the option that affects clinical care of the patient.
Why is it important to involve physicians in clinical documentation improvement (CDI)
programs?
Answers:
It encourages physician participation.
It helps justify the need for CDI programs.
It will eliminate the need to query providers.
It will help providers' time management. - It encourages physician participation.
Response Feedback:
Getting physicians involved in CDI helps to gain physician buy in and encourages other
physicians to participate and is a great way to educate physicians.
How can an effective CDI program improve patient outcomes?
Answers:
Maximize the reimbursement received
,Prohibit claim processing errors
Provide a detailed record of the care provided to the patient
Allow providers to support higher levels of E/M services - Provide a detailed record of the
care provided to the patient
Response Feedback:
The main goal for detailed medical records is to promote the continuity of care for the patient.
This allows providers to communicate with each other on the care that has been provided to
the patient. Coding higher-level services that are not medically necessary is not a goal to
improve patient outcomes.
In addition to facilitating high quality patient care, a properly documented medical record
verifies and documents precisely what services were actually provided. Other than the site of
service, the medical record may be used to validate:
Answers:
The appropriateness of the services provided
The patient's certificate of birth
The identity of the patient's extended family
The cost of healthcare benefits used for the year - The appropriateness of the services
provided
Response Feedback:
In addition to facilitating high quality patient care, a properly documented medical record
verifies and documents precisely what services were actually provided. The medical record may
be used to validate: (a) the site of the service; (b) the appropriateness of the services provided;
(c) the accuracy of the billing; and (d) the identity of the caregiver.
To maintain an accurate medical record, what is the recommended appropriate time for
provider documentation?
, Answers:
Within 48 hours of patient visit
A minimum of bi-weekly
During the encounter or as soon as possible
The end of each day for all encounters that day
Response Feedback:
The best way to achieve the most accurate, detailed documentation is for the provider to
document the encounter/services as soon as possible after (if not during) the encounter. -
During the encounter or as soon as possible
Which of the following sources, other than federal healthcare plans, may request the medical
records?
I. Patients
II. Providers involved with the patient's care
III. Employers for worker's compensation claims
IV. Private payers
Answers:
II and III
I, II, and IV
I, III, and IV
I, II, III, and IV
Response Feedback:
